Welcome to the PCSS training on standard medical management for opioid use disorder in primary care. My name is Mike Pantalon and I'm from Yale School of Medicine, I'm a Senior Research Scientist there in the department of emergency medicine, and I'm a Clinical Psychologist by training. I've worked with my colleagues, with patients like these in primary care in emergency medicine for the last 21 years, I'm very happy to be here with you today. In terms of my disclosures, I have no relevant financial relationships with ACCME defined commercial interests to disclose. The target audience for today is folks like you, because the overarching goal of PCSS is to make available the most effective medication-assisted treatment to serve patients in a variety of settings including primary care, psychiatric care, and pain management settings. The educational objectives for today are as follows: the overarching goal is for you to be able to provide evidence-based treatment for opioid use disorder, which we'll be referring to as OUD in primary care. At the conclusion of the activity today, you should be able to describe how to implement standard medical management or SMM for patients with OUD in primary care settings, you'll also be able to address common issues in treating OUD in primary care. So let's start with the question; why do we need standard medical management, why is it important? Well, we'll ask you to reflect on that, but what our colleagues are thinking is that because substance use disorders are vastly untreated especially opioid use disorder. The problem is that serious, 2.5 million people are thought to have opioid use disorder in our country, it costs our country $26 billion in healthcare costs, loss of productivity, and other expenditure. Sadly 115 people lose their lives to opioid use disorder predominantly via opioid overdose deaths each day, 115 deaths each day, so that's why we think it's important. But we also think it's important for you to reflect on why it's important to address opioid use disorder, and in particular why the use an evidence-based approach like standard medical management. In order to accomplish that, we're going to cover the who, what, where, when, why, and how, of standard medical management, so let's start with who. For whom is standard medical management? Well, of course it's for the patient, it's for the patient with opioid use disorder who is seen in primary care for other general ambulatory medical settings. So the psychologist, counselor, and social worker can do the psychosocial components only of standard medical management, and the folks above, the nurse practitioner, physician, and physician assistant can do both the psychosocial and the medical components of standard medical management. Because it is a combined approach, combining psychosocial and medical approaches, that's why we have this division of labor. So let's briefly review because I'm sure you have some experience the substance use disorders criteria or SUD. This criteria come from the DSM-5, and basically this is our main way of diagnosing a substance use disorder, whether it'd be alcohol use disorder, cocaine use disorder, and in this case, opioid use disorder. The way it's defined is a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of the following 11 symptoms, and two of these symptoms at least needs to occur within the last 12 month period. So you can take your time and read it but I will highlight each of the 11; taking opioids in larger amounts or longer than they meant to, wanting to cut down but not being able to, spending a lot of time and effort getting the substance, cravings or urges, not managing school or work or other obligations, relationships are affected negatively. Giving up social or occupational activities, using substances in dangerous or potentially dangerous situations, continuing to use even when you know it causes physical or psychological problems, and then the last two have to do with physiological dependence. The first one is needing more of the substance to get the same effect as we all know that's tolerance, or the development of withdrawal symptoms which can be relieved by taking more of the substance. So two of these 11 symptoms gives you a mild opioid use disorder, four to five of them gives you a moderate opioid use disorder, six or more gives you severe. In order to be treated with standard medical management which includes a medication for the treatment of opioid use disorder, the patient would need to be on the higher end of this severity, high moderate to severe severity. In order to put this diagnosis of opioid use disorder in context, let's look at the spectrum of substance use concerns. They start from abstainers to low and then high-risk drinkers because for alcohol we do have low and high risk amounts, for illicit substances for obvious reasons we do not. But in the pre-diagnostic realm, people begin to use substances in a hazardous way which means they are potentially harmful, that word potentially is very important because someone may drink and drive or use opioids and drive and get home fine without any problem, but that still is a concern because it is hazardous behavior, it could have led to harm. Then next step up is harmful use of a substance where some harm has actually been sustained, but a single event of harm does not give someone a diagnosis of a substance use disorder. Having engaged in impaired driving a single time even if some harm has happened does not necessarily give you the diagnosis, but that is very serious and considered harmful. So once we get into the substance use disorders realm, that's where someone has a diagnosis of a substance use disorder and based on what I just told you in the previous slide, if they have two symptoms it's mild, four to five it's moderate, six or more it's severe. At the most severe end, we have folks who have a co-occurring psychiatric condition in addition to the substance use disorder. Let's talk a little bit about the words we use to describe the patients with whom you might be doing standard medical management. While our society has to some degree accepted these terms in general, they are thought to be stigmatizing, pejorative, and unhelpful in the process of working with said patients. So the terms that you see on your screen here, alcoholic, drunk, addict, and so on, are terms to stay away from, now that doesn't mean that you're not going to slip up and say alcoholic or addict. We hope you wouldn't say drunk, junkie, lush, crack head, or druggie, but alcoholic and addict is what people refer to themselves as when they go to meetings or support groups about their condition. But what we're aiming for here and what the evidence suggests that is most helpful is a new language in addiction, and here are the four principles of this new language. People first, medically accurate, positive process, and stereotype reducing, there is some overlap among these principles, but basically by people first we mean name the person first, you can simply say a woman with, a 34-year-old man with, and then name the condition, a substance use disorder. Probably best to put in the substance class, so for example a 41-year-old woman with moderate opioid use disorder, so the person first or just simply person with opioid use disorder. Using opioid use disorder as opposed to opioid addict or alcoholic is simply more medically accurate, so person with diabetes is the same thing, so we're not saying person with high sugar, that would be the equivalent. We also want to use positive terms when we describe the process of working with someone around this condition, and later you'll hear me talk about a lapse versus a full-blown relapse, but we'll say those terms versus fell off the wagon which sounds negative. We want to talk about someone continuing to find their motivation to change as opposed to a resistant person, which is more positive and actually the evidence suggests that people are more likely to change if we use these terms. Overall using terms like opioid use disorder even if it confuses your patient at first a little bit and it requires some education, using those terms reduce stereotypes. So just a few more examples of medically accurate diagnosis, so instead of a social drinker which is really an undefined thing; person with low-risk drinking, instead of addict; the person with a diagnosis of substance use disorder. Hooked, addicted, physically dependent or substance use disorder mild to severe, double-trouble, how about dual diagnosis instead or co-occurring substance use disorder and mental disorders. So now that we have that front matter out of the way, let's talk about SMM. We talked about who, now let's talk about what. What is SMM? Standard medical management is an individual counseling approach for buprenorphine maintained patients with opioid-use disorder. So the buprenorphine is in fact the medical component of standard medical management, and managing the patient on buprenorphine in primary care includes the psycho-social component. So it's a really nice blend of the most minimally evidence-based and effective approach to working with these patients in primary care. So it's primary care based, it's minimal because it is brief, 15 minutes per visit after the first visit. It is protocol-guided, medically-focused, and evidence-based. So who may not benefit from SMM alone? So the vast majority of patients who qualify for buprenorphine, so again, opioid-use disorder, high, moderate to severe. But the patients who may not be able to benefit are those with medical contraindications such as opioid pain management. You can't take buprenorphine if you're on opioid pain management. Moderate or severe psychiatric disorders. Patients who are not able to minimally adhere to SMM guidelines, which we will get into, and it may not work or benefit well for patients with other poorly managed substance use disorders, especially sedative or alcohol use disorders. Now, this does not rule out folks with psychiatric disorders in a blanket way. They just need to be managed well. Their psychiatric concerns need to be managed well. Just like if they have another substance use disorder, it needs to be managed well in order for them to qualify for SMM treatment for OUD. So who can do SMM? Any trained medical professional, and keeping in mind the things I talked about before in terms of the division of life. What constitutes SMM training? Well, the first thing is that you need to have an approval to prescribe buprenorphine, an X-waiver. Provider training required for this is eight hours for physicians, 24 hours for nurse practitioners, and the same 24 hours for physician assistants, plus this SMM webinar or a live in-person training and continuing education on SMM. We will talk about that a little later in the webinar. So let's talk about what we would like to happen if we're doing SMM? Safety first, in all concerns. So it actually helps the patient and his or her loved ones be safer with regard to the opioid-use disorder. We would like for the patient to be educated, motivated, and we would like for them to be less stigmatized by this more positive process. It's not just the language, simply bringing opioid-use disorder treatment to general medical settings, especially primary care, is in and of itself de-stigmatizing. We would also like for them to receive the treatment, the full complement of the treatment components that I will go over with you, and ultimately, for them to achieve abstinence from all illicit opioids, and along the way, a reduction of use and problems associated. So while abstinence is the ultimate goal, it may come quicker for some than for others. Our patients intolerance of first reduction of use and problems associated with it will ultimately help the person get to abstinence. So where and when can you do SMM? Well, any medical setting and on-demand to the extent possible. What are the criteria used to determine level of care here? So just like we use from the American Society of Addiction Medicine, or ASAM, their adult admission criteria, we'd like to give you a little guidance on where buprenorphine maintenance within SMM falls. So here are the six levels or dimensions that determine the level of care. Here are the six things one needs to know about in order to determine what level of care. Now, I encourage you to get the proper documents and training around the ASAM criteria. But for our purposes, it's helpful to know that we need to take into consideration the degree of intoxication or withdrawal potential of the patient, other medical conditions and complications, emotional or psychiatric conditions, as mentioned previously, their readiness to change, i.e, their motivation, the potential for relapse and continued use, and the recovery environment. How much social support exist for this patient? So if someone's withdrawal potential is high, that's fine because we're giving them a medication. If they have medical conditions, they need to be managed well. So good management of hypertension, diabetes, asthma, same thing for their psychiatric conditions, they need to be managed well. In terms of readiness to change, a patient does not need to be 100 percent motivated to completely and immediately become abstinent from opioids, which in many cases in treatment clinics for OUD is a threshold requirement. Here they just need to be motivated to adhere to the guidelines and protocol of SMM, which we will get into shortly. It is important to take into account their relapse potential. But for providers doing buprenorphine maintenance, we understand that the single best thing we can do to help people from relapsing to opioids is to provide agonist maintenance treatment like buprenorphine, and their recovery environment. If someone is not able to have at least some social support for this, and they are routinely in a setting where they are barraged with offers of opioids and things that remind them of opioid-use, and that trigger them in that way, that person may need to first find a better recovery environment before they can do this care. But in general, here are the dimensions to consider, and we will look at the actual levels of care that ASAM lays out. Opioid maintenance therapy like buprenorphine is not leveled, meaning it can occur at any of these levels. But it's important to note that it is preferable to try someone on opioid maintenance therapy like buprenorphine and standard medical management, before getting to the higher levels of medically-monitored, intensive, inpatient services. In general, in our country, we are quick to refer someone to an inpatient rehabilitation center that's medically monitored, or quick to refer them to detox. But detox alone and residential settings where buprenorphine is not available generally are not as effective, in general, are not as effective as buprenorphine maintenance. So if a patient is able to follow the protocol and be adherent to it in terms of SMM, and any other medical or psychiatric problems are well-managed, then you should really consider giving them a trial of SMM with buprenorphine. So why are you thinking about doing SMM? Now, of course, we can't have a conversation right here, but there are discussion boards where you may write about this. But at this moment, I'd like you to take just 10 seconds and to think about why are you considering doing this? Where are you learning about SMM at this particular time? Why might it be helpful to you and to your patients if you were able to provide this? Take a moment. Good. Now, some things you might be thinking is, ''I'm already treating these patients for other conditions. They're already in my practice. Why not be able to comprehensively treat them?'' Or you might be thinking about the opioid crisis. ''How can I do my part? Is it true that buprenorphine maintenance does work as well and is just as easy to do in a primary care setting as the treatment of other chronic medical conditions?'' Or in fact that the evidence suggests that that is true. Those might be your reasons. They may not be. But consider what your reasons are as we progress through the webinar. Now let's talk about what you're worried about because this is something that you're probably not doing at the moment. If you are, congratulations and thank you for doing it and this is a brush-up for you. But if you're not, what are your concerns? What might be the obstacles? Well, they could be confusion about how you might as a general practitioner be able to do this. I assure you, you can and you will be able to do it. You might be irritated about the lack of access or the difficulty with which your patients face in getting good opioid use disorder treat, and these obstacles can apply to you or to your perceptions of patients with opioid use disorder. They may be irritated about treatment. They may have low motivation. Perhaps, you're concerned about disagreement with patients or their high levels of dependence. Whatever your concerns are, you will see that SMM lays out something that's easy to follow and understand that makes it easy to handle resistance or irritation from patients, and that actually gives you strategies to motivate patients. Now, there may always be disagreement. Think about patients that you routinely see. Perhaps, there are times where there are disagreements. That's part for the course human nature to some degree. But in SMM, we give you a way to agree to disagree with patients and still proceed in a positive process, and in terms of the medication, even folks with high physiologic dependence on opioids, buprenorphine does work. We will also talk about helping your patients access additional support services and treatment to make SMM be as effective as possible. Okay. So the first goal of our webinar is how to implement SMM. All of what we just discussed is to be reflected on good foundational knowledge in order to implement SMM. So I would encourage you to refer back to that. But let's get to how to actually implement standard medical management. Here's an overview. We have goals, elements, roles and a sequence of SMM. So what are the goals of SMM? What are the elements that comprise it? Who's to do what? What are the roles? What's the order or the sequence? Let's start with goals. The two main goals are abstinence and opioid use for emission, as well as a reduction of use and problems. The ordering of that can vary from patient to patient. So don't worry that you can't take off abstinence as the first goal. Perhaps, someone reduces their use first. Perhaps, they use in a way that causes fewer problems. In fact, both end up leading towards abstinence and OUD remission. Remission by the way of opioid use disorder is the absence of those 11 symptoms that we discussed when we went over the DSM-5 diagnosis. I would encourage you to refer back to that frequently. But the absence of those symptoms over a certain period of time, six months or greater is early remission and then 12 months or later is prolonged emission. You may find that patients will be surprised or especially their family members when you educate them about the fact that there is in fact a remission from addiction or opioid use disorder. Okay. So those are the goals, the elements of SMM. There's a long list in front of you that you see. I won't go over every single word because you will have a cheat sheet for this along the way, and we will walk you through each one. But they generally chunk into three areas. You're going to provide buprenorphine treatment in primary care. You're going to motivate your patients and then you're going to advise them. You're going to provide the buprenorphine. Motivate your patient and advise them. Let's go into what is entailed for each of those. So the provision of buprenorphine is actually prescribing it, doing the induction and maintaining the patient on the appropriate dose, and we'll get to that in a little bit. Educating them about OUD and buprenorphine treatment, and then monitoring both their compliance as well as their drug use and symptoms as they progress through the treatment. So what we just went over is the provision of Buprenorphine. In terms of motivation, you want to start by simply encouraging. You don't have to jump right into doing a full-blown motivational, interviewing or motivational enhancement therapy. We have found in our work in primary care with these patients that very little goes a long way if done correctly. So that'll be my job to make sure that you can learn how to do that correctly by the end of this webinar. But to simply describe it, we encourage patients to shoot for abstinence and treatment adherence. You first start by encouraging them to get the support that they need. Either through friends and family or mutual support groups or self-help. If encouragement repeatedly in a good treatment rapport with the patient doesn't work, then you will get some strategies around motivational enhancement that we have shown work whether it's a physician or a counselor or a nurse doing it. So we'll go over some brief motivational enhancement, and then last three things that you see on this slide have to do with advising the patient. So brief advice modeled on something called standard drug counseling. You do not have to be a therapist or a psychologist or a psychiatrist or a drug counsel to do this. But brief advice based on it, advice to address medical complications of opioid use. So if that's with you, then you can just go ahead and do that. If that needs to be with another medical provider, then advising them to see that provider, and then advising them to follow up on referrals to other specialty services in the community. Be they for additional psychotherapy which is not always needed but sometimes is or employment services, housing services. So the elements of SMM chunked provision of BYU, encouragement or motivation and advising. The roles of SMM and we've talked about this a little bit before. For the physician PA or APRN who are x wavered, they can do all elements of SMM. The nurse needs continued supervision by the physician, and that's the one caveat, but they can meet with patient for the initial and subsequent monthly appointments. A nurse can also do all elements of SMM except the actual prescribing of the buprenorphine. They can meet with a patient weekly and do all of the other SMM components. Counselors can do only the psychosocial components, and that's helpful if an RN is not available and they too could meet with the patient weekly. So let's talk about the order or the sequence of SMM. You first have the initial session which is 45-60 minutes, and then you have subsequent sessions which are around 15-20 minutes. So the initial session and the subsequent sessions. Let's go over the initial session first. It is 45-60 minutes long. Again, you have a little bit of a list of things to do, but trust me, the explication of the full list allows you to just checklist yourself through it and based on our experience and training lots of providers, it does scaffold the approach and give a nice infrastructure so that you are confident you're doing everything you need. If this list seems too much, let's just pay attention to one at a time and you'll see that you likely do virtually all of these with your other chronic medical patients just with a different twist given that here it's opioid use disorder. So the first thing is to establish rapport with the patient. I will let you know if you want a scripted way of doing that, exactly how to do that. But basically, what it means with opioid use disorder patients is to not repeat, not jump right into the opioids. They are regular medical patient, and with regular medical patients, by which I mean people with diabetes, asthma, hypertension, what have you, you take a few seconds to say, how are you? How is it going? What's on your mind? How are you feeling generally, rather than immediately spotlighting with the patient. In this case, with OUD is very concerned about and has been stigmatized in the past. Review the medical psychiatric and substance use treatment history. Quickly review who they are aside from their substances; place of birth, education, employment, family supports, and in fact, that could be part of what you address, perhaps not all of it as you establish rapport. Review the diagnosis of OUD with the patient, and that is not simply to say you have opioid use disorder. Many patients with opioid use disorder will tilt their heads and be a little confused when you use that terminology. But because we are using non-stigmatizing language that is perhaps different from what the patient hears elsewhere or calls himself. It may take a few seconds of educating the patient that we follow medical diagnostic language, and here's what that means. You might even show them the criteria and point out which ones they met in order to get opioid use disorder. That alone is a very motivating and sometimes inspiring thing for the patient because they are being treated like I quote, "regular patient". The next bullet is develop the treatment plan. Again, we have a model treatment plan for you including buprenorphine. Advise abstinence from all drugs, but do not be immediately insistent on it. Refer to mutual support groups, especially if the patient doesn't have other family or friends, social support. Motivational enhancement as needed, but encouragement is the first step there. Providing other referrals. Delineating and reinforcing the program guidelines and answering any questions the patient may have. Now, I will walk you through each of those, but let's reiterate some foundational skills that I'm sure you all have, but since we all learned these first, long ago, it's always helpful to review them. The foundational communication skills I'm talking about here are reflective listening and asking open-ended questions. But there'll be a little twist. You'll see that in a moment. Reflective listening is simply mirroring back what a patient says to you. Not everything that they say and not in a very robotic or pirating way but in a paraphrased way. So if a patient says, "I'm glad I'm here, but it was hard to get myself to try this", you might say, "It sounds like this was a bit of a challenge, but you're happy you came, I am too." The I am too is more like a validation and then additional part, but the first part is you reflecting what they said. Open-ended questions on the other hand, are questions that are asked with the wh or h words. What brings you here? Why did you think this might be a good idea? How do you feel about being here? Or something like tell me more about why you ultimately decided to come. That does count as an open-ended question. But basically, open-ended questions are what you ask when you like what the patient is saying. It's motivational, it's adherent to the protocol and you want them to expound on that to tell you more. The more the patient hears themselves arguing in favor of adhering to this protocol or talking about its benefits, the more motivated they will become. The more you reflect back those motivational statements, the more motivated they will become. Now, here's the twist. Even though I'm talking about you reflecting and asking open-ended questions about the motivational, the positive things the patient says, and that's mostly what you would want to attach these foundational skills to, you may also be able to reflect negativity or reluctance or even outright resistance. It's okay to reflect that, but the strategy here is to reflect more selectively the positive rather than the negative. So the patient says, "I really didn't want to come, but ultimately, my husband convinced me", the positive part is that she was convinced. The negative part was that she didn't want to come. Now, you might not build great rapport if you don't give some attention to the part that reflect that she didn't want to come, but you want to give more reflective or open-ended question attention to the positive part. So for example, you might say, "So even though at first you didn't want to come, ultimately, there was something that happened in your conversation with your husband that made you decide, yes, I want to come." So you see that's paraphrased, but 75 percent of that reflection is about her ultimately deciding to come and even reflecting on her autonomy or freedom, that choice that she decided versus the initial thought that she didn't want to. More on these two skills as we talked about motivational enhancement later but those are our foundational skills and they are important because people really only listen to one person, and I'm sorry, they're not their doctor and perhaps not even their mother or father, but its themselves. So reflecting and asking open-ended questions helps patients reveal the motivation that they themselves have. If they hear themselves say it rather than just have it locked in their minds, they are more likely to be motivated here. So remember that long bullet point slide that had all the things you do on the first initial session here of 45 minutes, now we're going to go into each component. Establish rapport. So here we're going to introduce yourself, explain what's going on, and ask permission. So for example, now, if you like scripts, here they are and you can transfer them and use them in any way that you'd like. If you don't like scripts, then these are simply examples or FYIs, and feel free to modify as you see fit as long as you keep the essence of the idea here. "Hello, I'm Dr. Pantalone. I'd like to talk to you about how you're feeling today. Would that be okay?" So it's an introduction, but it's also that building of rapport that does not immediately highlight the opioid use disorder. You don't have to. That's up to you. But do you mind if I ask you a few questions? Now, you might ask yourself why would I be encouraging you to ask permission to do something that patient has tacitly giving you permission to do by virtue of their attendance today or at your office? Well, the reason we do that is because these patients prior to coming to you have probably been so confronted, pushed, coerced, forced, strongly urged to go to the treatment that we almost have to over-correct the removal or the perceived removal of their freedom by reinforcing their autonomy and saying, "You don't have to do this even though you're you're here, but do you mind if we proceed?" Pause, and let them say, "Yeah, that's okay." They may say, "Well yeah, that's why I'm here." That's totally fine. Don't let that throw you off. Review their problem. So again, we're going to ask some questions, reflect on what they say, and give them some information. Here's a sample script. "Tell me a little bit about your health in general, past medical history?" "What medical problems have been caused by your use of opioids?" In the first part, I already told you a little bit about opioids and what other problems might be related to your opioid use. Mood issue such as anxiety or depression, social issues, legal issues. Review the diagnosis with them. As I mentioned before, go over the DSM, provide the evidence for the symptoms that you feel that they are evidencing and summarize. Again, you have some standard language, but it's basically based on your intake and the information you have given me don't meet criteria for opioid use disorder in this way. You might trace their history running up to that to some degree. But remember, the diagnosis is based on the symptoms in the previous 12 months. You end by saying, "Take it together, these problems would be classified as opioid use disorder, severe." Developing a treatment plan. The single most important thing to say at this point is that this is a treatable condition, and here's one of the best ways of doing that with buprenorphine. But the counseling that we will offer you here, you don't necessarily have to go to therapists, but the counseling we offer here is a critical component. So it's highly treatable, you can review any evidence if they would like to hear about that, and there will be some references at the end that can be helpful with that. You can explain how buprenorphine works, how it acts on opioid receptors to prevent withdrawal and taking in a reliable manner in a therapeutic way, at a therapeutic dose that the person will experience much much less if any of a need for heroin, fentanyl or whatever opioid they currently use. But you will also be talking about how to cope with triggers and urges or cravings to continue to use opioids and how to change their immediate environment or lifestyle in order to help move them towards use reduction and ultimately abstinence. Other referrals may also be available to them. Here's the sample SMM treatment plan that covers each of the components that we list in the initial session. Again, we go over the goals, which in a very concrete and immediate way. As for the patient, provide urine samples, negative for illicit opioids within one week. That's a short-term goal, but it may take a little longer. So sometimes tracking quantitative urine results could be helpful provided you can feel that they are accurate and reliable. Two, a complete cessation of illicit opioid use based on patient report, and three consecutive weeks of negative urine toxicology tests. Those are the ultimate goals, but the methods are really more important at the initial session and what this treatment plan lists is the bullet point lists that we had before for the initial session. Providing advice. So the first kind of advice we want to provide is to recommend working towards achieving abstinence. Now, don't get me wrong. If the patient seems poised to do that immediately, support them to do that immediately. But many are not. So telling them that we're going to help them work towards abstinence. They'd balanced in fair way, where we're not going to be satisfied only with a reduction, but we're also not going to immediately pressure someone to achieve abstinence immediately. But advising them to attend all meetings with you, the physician, with the nurse, with whoever is doing the psycho-social component of SMM and all referrals, will help towards this end. We also want to advise them to either avoid or cope very differently with triggers of drug use, the things that precipitate typically their drug use and to attend mutual support groups. Those are the things we're going to advise. In terms of the standard drug counseling advice that we talked about earlier is, we want to basically advise them around things called triggers. Trigger is just the common language, so it's hard to think of another word there, but basically it's the antecedent or the thing that happens before someone who uses, anything and everything that happens before someone uses is a potential trigger. So the best way to summarize and for you to remember what your standard drug counseling advice is around these triggers is to use the acronym RACE, R-A-C-E. So the R stands for recognize. You went to help patients have recognize triggers as early as possible. So first, what usually precipitates your use? In what contexts or situations do you generally use, and maybe advise a patient to make a list of them. But as they go through their days and weeks on this program, they should start to recognize their triggers well and as early as possible. The sooner they recognize them, the sooner they can do something about them. The three main things that we would advise patients to do with these triggers is, avoid them, cope differently with them, or escape from them. As you see, the A for avoid makes up the second letter in our acronym, the C in cope makes up the third, and the E in escape makes up the four. So once they've recognized triggers, say to them, you have options here. I know you can't avoid all triggers, but to the extent that you can avoid a bulk of them, you just won't have to deal with it at least for a time until you get up to a therapeutic dose, until the medication helps you as much as it can. If you cannot avoid a trigger, lets imagine that you used to use illicit opioids with the coworker and you can't or shouldn't have to quit your job and you're going to see this person, you may need to cope differently with that person. That's an example of a trigger that cannot be avoided. That said, you might choose to avoid that person to some degree at work however much possible. But you may advise them to cope differently with this person by communicating with them differently and informing them that they you are now in treatment for opioid use disorder, and that they would greatly appreciate their coworker not offering illicit opioids to them or any opioids. That's just one example, but there is a manual on SMM and that is free to anyone who wants it. Within it, there are a number of other ways to advise folks to cope with their trigger. So I'll give you one more example. So if somebody says, anger or anxiety is a trigger for them, advising them to find standard ways, routine ways to deal with irritation or anxiety such as relaxation or yoga or meditation, finding a group to learn how to do that or an app on their smartphone to do that. That's another thing that you can suggest. Even though patients don't like the fourth one, I think it's incumbent on us to say it is fair and it is admirable and not weak, repeat, not weak to escape from a triggering situation, even if you have to make up a white lie about it. If you run into someone with whom you used to use on a street corner, tell them, "I forgot I have an appointment. I need to leave. Nice to see you." Escaping from this situation is also a good strategy. So the next thing that you would advise patients about in this initial session and in an ongoing way is referrals. So sometimes, simply asking or repeatedly throughout their treatment, say, with you," What else might you want or need help with?" Again, I always tell people to pause. We forget to pause. So what else might be helpful? Sounds like you'd be willing to consider referral for help with housing, therapy, transportation, relationship counseling. You don't have to push it. You don't have to force it, but listen for it and explicitly ask, "What else can I help you with?" Then you could say, "Let's go over some options." If you don't have them handy, say, "Well, we have someone on staff who can give you a few pamphlets that would be helpful." That's it. All referrals, however, should be evidence-based. So whether it's for medication, let's say, Antabuse or disulfiram for alcohol or counseling. If you're going to refer someone to additional counseling, it should be an evidence-based counseling for opioid use disorder or whatever the condition is. I will give you a list of evidence-based counseling approaches for addiction in a moment. Family intervention. So where should someone go if they're a family member or if you're patient says, "My family would like to learn more about addiction." Where should they go? Self-help, mutual support groups, and coaching. There is a lot of recovery coaching out there now some as evidence-based, some as less so. So do either task someone in your practice to look up what is evidence-based in each of these areas, I will give you some guidance, but the key here is if we're going to be doing some of the best evidence-based treatment for the OUD, anything else you refer them for should also be evidence-based. By that we mean that the research that backs it up is done in a robust way based on a number of randomized controlled trials with each of the following components clearly diagnosed and assessed participants, manualized treatment, attention to confounding factors, operationally defined outcomes and measures, measurement of the integrity of the treatment that's offered, and controlling for statistical dropout. So the other counseling approaches to which we would refer for substance use disorders generally, and this includes opioid use disorder, but there may be little caveats along the way. So this is a blanket list. These are in general the most robustly evidence-based treatments for a variety of substance use disorders. Motivational interviewing, or motivational enhancement therapy, it's very similar. Cognitive behavioral therapy, individual and group drug counseling, community reinforcement approach, contingency management, Twelve-Step Facilitation, cognitive therapy, Standard Methadone Counseling. But if they're on Methadone, then they're not going to be with Buprenorphine, but we thought it's important to note that that is, in fact, an evidence-based. Counseling approach and then CRA plus Family Training, the acronym for which his CRAFT. I will note that is an alternative to Al-Anon. Al-Anon is a twelve-step approach similar to AA or NA, Alcoholics Anonymous or Narcotics Anonymous, but Al-Anon its for the family members. CRAFT is an evidence-based mutual support group for family members, whether they are dealing with their loved one who's already in treatment with you or it can be used to help the family guide their loved one into treatment. So just an FYI there. So when compared to standard interventions, it works far better. So these are the treatments that are referred to. You're probably familiar with most of them. The ones we get most questions about however is community reinforcement approach and contingency management. I believe you can get more training on these in other PCSS webinars. But in short, community reinforcement approach is a type of CBT, but it focuses more on engaging the patient in reinforcing or positively engaging activities that are alternatives to their substance use. Contingency Management is one specific way of doing that, and that is setting up a system where the patient is systematically rewarded for reduced drug use or for negative urine toxicology screens. Now, of course, both of those are out of the realm of any primary care practice, but it's good for you to know this list. Someone from your practice can interview a provider to whom you might refer if your patient needs more psychotherapeutic assistance. The last thing I'll say is that, Twelve-Step Facilitation is in fact a one-on-one professional psychotherapy built on the first four steps of the twelve-step approach. It is not going to meetings, it's not getting a sponsor, it's not doing step work, although all of that could be great, but it's professional psychotherapy that facilitates someone involvement in twelve-step groups and doing that sort of work. It is evidence-based, but one of the harder treatments to fight. Actually, one other note here is that when the research has been done on opioid use disorder, none of these are as effective as SMM for moderate to severe opioid use disorder. That does not mean that SMM is more effective, but when we've done studies comparing SMM to SMM plus Cognitive Behavioral Therapies or SMM compared to SMM plus Individual Drug Counseling strategies provided in a primary care setting, SMM alone is equivalent to those other treatments. They have similar outcomes. So SMM is the first place to start with patients who qualify for it. There's no reason to think that everyone with opioid use disorder needs psychotherapy on top of it. Some may, some will, but SMM is comparable to its use when you compare it to patients with SMM and a couple of these other psychotherapies added on. So reinforcing program guidelines is another important component here especially the visits. So here's a script for you. In order to stay in good standing with the program, we expect you to attend all scheduled sessions, take the medication as prescribed, adhere to all referrals, provide urine toxicology samples when asked, and cooperate with medical procedures. Answer any questions the patients may have and as you might have guessed, I'm going to ask you to pause. So what questions might you have for me? Pause even longer than the five seconds. It's okay to have questions. Take a minute to consider what we've gone over. Imagine we've started working together, what may come up? Here are some questions patients frequently ask. I'm telling you that you will avoid future issues or questions with the patient if you tell them up front what your experience is about other patients questions. That will model for them that it's okay to ask questions and it may give them some important information. So even though we can't try it right now because we're not in a group setting, I would strongly encourage you to practice what we've talked about in this initial session with two other people in your practice or to other colleagues you can find anywhere. Take turns playing the role of an SMM provider during the initial session, a patient, and someone who observes the provision of the first session and then switch roles. So there would be three role plays so that you could play each role at some point. After you've done this, debriefs some and decide what's your take-home message that you would share with other colleagues or that would help you in the provision of SMM to your patients. Subsequent SMM sessions follow a similar format but it's a little different, so let's go over each bullet point. There's a lot of revealing, but again, it falls within the provision of BUP, the motivation of the patient, and the advising of the patient. So BUP, motivation, advised. So in terms of BUP, we're going to review their medication adherence, we're going to review their substance use, their response to the medication, and then the lifestyle changes or participation and mutual support groups. We're going to motivate patients to be abstinence from all drugs to the extent possible and if not to severely reduce their use, and to motivate them to get support for this, and encourage them to remember the education you've given them, and to use formal motivation enhancement strategies around any non-adherence, advise them to continue adhering to their referrals or make new referrals, and then dispense the medication. So let's go through each in turn and this will go a little quicker than before because it's similar to the initial session, but let's review adherence and use. So we start with an open-ended prompt, how did it go with the buprenorphine last week? When were you not able to take it or forgot to take it? Why would I say that? Usually, we say so you took it all the time and we're nodding as we're saying that. That's good, I guess in general for other concerns, but here we want to model for the patient openness and transparency, and so giving them at least initially some permission to reveal once perhaps of not taking it. That will help you immensely because you will then know what's the context within which they forget. What's the trigger for forgetting or not wanting to take i? So a little permission to not be a 100 percent adherent actually helps them become a 100 percent adherent. Tell me about your last drug use since we met. Same issue here. How much? When did you use? If they say, "No, I didn't use at all." Well, that's great. When might you have been tempted? When did you think about it? Let's review your talks results and then you've gotten some positive feedback. It seems that you're doing well in that and everyone who you're talking to can and should get some positive feedback first. If there's some negative feedback to give, then you'll give that second, but always fill in the blank here first. You seem to be doing well in that you came today and even though it wasn't a hard week, it's hard to take most of the medication, there was an episode of drug use, the most important thing is that you're here, the somewhat. Negative part is that it was hard to take the medication, let's start with that and then you start problem-solving. But giving them the positive feedback first will always help them be more open and productive with the negative feedback. So let's review their response and any negative components here. How's the medication working for you? Tell me more about that. What's working well, what's working less well? Is there anything more serious about your response to it that we should talk about it? Anything more pronounced? How's the program working overall for you? Again, give them positive feedback on their response. If the medication is not working well for them, if they're having side effects, then based on your way of retraining you do need to attend to those right here and now. But working in that medical component within this psycho-social structure does lead to patients being open and transparent about what's that issue and that always helps you solve the issue more readily. As you review their progress down the road, it's helpful to keep in mind that early remission means no symptoms from that list of 11 in the DSM-5 that we went over earlier in the past 3-12 months, and before I gave you a six-month mark but actually in the revision of DSM-5, no symptoms for 3-12 months is early remission. They don't have to anymore wait until the six months to be on early remission, even three months. There is however one exception. They can still have craving. Craving was one of the symptoms. So it's the absence of the remaining 10 that gives you either early or sustain remission. If they have none of those 10, even if they stop craving and 12 months have gone by, then they're in sustained remission. This will be very inspiring and motivating to patients. Many patients don't know that we even consider it a possibility to be in remission. Patients think that they're recovering always. While that's fine and if a patient thinks of themselves as somebody in recovery, to give them this bench mark can be very motivating. It's also motivating when you're giving feedback on their response to treatment to know the difference between a lapse and a relapse. A lapse is a return to use that is less severe than their last period of use. A relapse however, is returning to the same level of previous use or greater than it. Too often we'll call everything a relapse, whereas many things are lapses. So when somebody comes back and says, "Yeah, I use, I really thought this treatment was going to work," and you note in your chart that when they came to you they were using every single day for the prior six months and now they used once in the last week since you saw them, even though that is a concern to review, that is not a relapse. That is actually progress. I would hesitate to even call it a lapse. But if somebody had been, let's say they were in the program for a month and they were not using at all, and then they used once and their prior history was, as I described a moment ago, using every day for six months, this onetime use is a lapse. They may even call it a relapse or that they messed up, and say, "Well, actually that's a slip or a lapse." "Oh, really? What's that?" Then define it for them. Very, very motivating. Please, keep that in mind. Assessing behavior change has to do with the behaviors outside of the protocol of the SMM, so you'll ask things like, how are the mutual support groups like AA, NA? What is a evidence-based mutual support group? SMART Recovery, S-M-A-R-T, it's an acronym, but SMART Recovery follows cognitive behavioral principles of mutual support. It's not therapy, but it is our single evidence-based mutual support group. Now, many, many people, millions of people have benefited from AA and NA according to their self report, but because of the anonymity it is, according to AA, impossible to do controlled studies of it. Now, we do know that the more groups and meetings patients go to, the better they do in treatment. But those are for the self-selected group like AA, that engage with it. If they don't, there are other alternatives. SMART Recovery is one and that is evidence-based. There is also, depending on where you are in our country, there is LifeRing, which is also more cognitive therapy based. There is Refuge Recovery, which is based on meditation. It depends on where you are, but SMART Recovery is probably your best alternate for a mutual support group. Ask them what do they like about the group? What's helpful? How about the other referrals? If they didn't go, how come they didn't go? Is that not a good match? Can we set you up with a different referral? But also, and I would say perhaps most importantly, what strategies have helped with reducing use and avoiding triggers, or coping with them differently. Each session should have some discussion. What are the triggers? What are the cravings and urges, and what are you doing in a productive way to respond to that? So again, race, this is something to remember and for each session to cover. The difference between a craving and an urge. To keep in mind, a craving is an internal wanting or a desire. Even a memory of a desire of drug use is a craving. An urge, on the other hand, is some movement or behavior, or planned behavior that moves you towards it. So if I am stressed out, I might have an internal desire to use Opioids if I'm the patient. But an urge would be calling up someone who could procure me Opioids, that's an action. So provide advice, again, you're doing very well. You should be proud. Keep it up. Our advice centers around the same things as before. In fact, to some degree, you'll sound like a broken record each session, but it's reassuring and a good structure for you and the patient. So advise him to adhere to SMM visits, abstinence or at least a reduction of use or the problems around their use. Support group attendance, advise around the referrals and avoidance of all triggers and if they can't avoid them to spend some time figuring out how to cope with the triggers differently. Now, motivational and enhancement. So if the provision of [inaudible] and your encouragement and advice doesn't lead to adherence on everything, then one by one for each non-adherent behavior, you could do a very brief motivational enhancement. This is actually evidence-based, based on motivational interviewing and the brief negotiation interview that is done in general medical and emergency department settings. So here's how it goes, choose a target behavior. So if a patient is not going, let's imagine that they're not avoiding triggers, that they keep slipping because they keep facing the same trigger. Let's imagine that they're not avoiding that co-worker and they still have lunch with that co-worker. They still listen to that co-worker talking about their own Opioid use, and you've been advising and encouraging them to stay away from that person. So you might decide that's my target behavior and I'm going to use this brief motivational enhancement to motivate them to stay away from that trigger. Or at least cope with it differently. Here, are your steps. But remember, you can only focus on one target behavior at a time. You cannot, repeat, you cannot motivate them to come to SMM sessions, go to NA and avoid this co-worker in the same motivational interview. You need to do them each one at a time. That's why we gave you a very, very brief motivational strategy. So choose a target behavior. In this case, the target behavior is to avoid this co-worker who is a trigger. So we do a strategy called the readiness ruler. So we start out by saying, well you're doing really well, you're adhering to this and that and the other thing, XYZ, and at the same time, not but, but and at the same time, I would encourage you to avoid that trigger that we've been talking about, that co-worker at work. How ready are you on a scale from one to 10 to avoid this person or at least to tell him that you can't have lunch with him anymore and that you're in treatment for your Opioid use disorder? One means not ready at all, and 10 means totally. So one in essence is a zero and 10 is totally ready. The higher the number, the more motivated or ready they are to avoid this person at work. Get them to give you a number. If they can't give you a number, get them to at least say not at all, in the middle, totally, or somewhere in between there. Here's the tricky part. You're going to want to ask them how can you be more motivated? But I'm telling you, do not ask them why they did not pick a higher number. Do not ask them why they aren't more motivated. Do not ask them what it would take to get them more motivated. Here's the correct follow-up question. Why didn't you pick a lower number? Now, at the risk of taking too long on this, but I think it's absolutely critical. If you get this down, you'll be expert motivational interviewer and you'll be able to do it repeatedly without even thinking about it. But the idea here is to ask someone why they have any even small amount of motivation to do the thing you're asking them to do. What happens is when you ask them why they didn't pick a higher number, they feel judged and they don't have that higher level of motivation, you will simply get excuses and reasons why they can't do it. But if you ask the unexpected and somewhat irrational question, why didn't you pick a lower number? Then the person needs to reflect on why they have any motivation, and the patient here will say things like, well, you're right because I start to crave as soon as I see him. I tried just steering the conversation elsewhere, but it doesn't work. I do really need to stay away from him. So one to 10, how ready are you to stay away from him? Get a number, ask them why they didn't pick a lower number. If they look at you like you have to say, yeah, no, I don't want to know why you're not higher, what you can do to be a higher number. I want to know why you have any positive reasons about trying to stay away from him. Then reflect on those reasons. That's your evidence-based, ultra brief motivational interview. Finally, we want to talk about new referrals, and again, simply as you've learned before, ask and pose what else might you need help with and we can get you those referrals. The second Webinar goal is much lighter in terms of its load. So don't worry, we are nearing the end here. It's to address general strategies, frequently asked questions, and then transitions and transfers. So our general strategies, as you may have already gleaned from my presentation, is that we are to be positive, empathic, hopeful, patient-centered, and motivational. In brief what this means is, no matter what's going on, your stance is that there's always something we can do to improve that. Even if that ultimately means a transfer to some other level of care, that stance will keep the patient positive. Empathic means, well, let me tell you what it doesn't mean. It doesn't mean you're okay with everything. It just means that you understand that this is a struggle and even when they're not doing well, that there's a part of them somewhere in there that wants to do well and let's address how we can help that part of that person better to be hopeful. The people who stay in treatment are the people who ultimately do well, and for some it could be a career in treatment. But there is always reason to hope for better. There may not always be reason to hope for perfect or complete abstinence, but there's always reason to hope for better. Let's always take it from the patient's perspective at least first. You'll always be able to give them your perspective. But always start with them and say, "Okay, so things have not been going great, but how do you sum it up? What do you think is at play here? What do you think could be helpful here?" Even if they want to tell you what you could do, that could be more helpful for them. Motivational means not asking why they aren't more motivated or how they could be more motivated. But by persistently asking, "Why do you have any motivation at all?" Not in a sarcastic way, but I always want to learn more about why they have some motivation rather than why they don't have more. Using the ruler, one to ten, how ready are you to make this positive change? Get them to give you a number and ask them why they didn't pick a lower number. In general, we want to reinforce their autonomy. So do that and do agree to disagree and always leave the door open if things come to a halt and I like to ask, "What would it take for you to consider a change here because we tried what we have. Perhaps you have some insight." But do not go the way of old school addiction treatment where we used to think that shaming, blaming, preaching, confronting, and guilting will help people change. You may have some feelings inside of you, some irritation or desire to confront. That's human nature, that's normal. But simply because you have that feeling, it doesn't mean it's an evidence-based thing to do, process that with your colleagues. But catastrophizing, withholding help, threatening, that does not help an opioid use disorder patient change. So here are some frequently asked questions by patients. So what if a patient says any one of these things. "I'm worried the medication isn't holding me," or "I've tried NA, it doesn't work for me." "I don't want to totally quit, I just wanna cut down." Well, the response to all of these is first, "Okay, I hear you. So you're worried a medication isn't holding you? I hear you," Prove it by reflecting. Then you say I'm concerned, and then medically to the extent that your waiver training has trained you, address it medically. So take the pressure off the person for a moment. Look at it as a medical question. But then say, "Well, let's see what else we can try. What do you think we can try that might be different?" Take that in. If they have a good suggestion, try it. If they don't say, "Well, I hear you, but would you consider this?" So for example, they've tried MA but it doesn't work for them. Okay. "Well, have you tried a different NA meeting? Each meeting is different." "No way, I'm not going to NA." "Well then there are other mutual support groups." Give him alternatives, like SMART Recovery, and then encourage them to do that. But with any or all of these, approach it first with a reflection, then concern, then ask for their input. Give them your advice, if they take it, great. If not, do the readiness ruler and motivate them. Transitions and transfer. So you're going to have many, many more transitions and transfers. If you follow the inclusion criteria correctly, there'll be very few transfers, but transitions are moving from weekly visits to monthly visits for stable patients. What's the stable patient? They're tolerating their maintenance dose, not the induction dose, the maintenance dose. They are largely abstinent, and if they're only largely abstinent, not fully abstinent, then I would also add that the use that they are engaging in is not causing problems that would allow you to tick off those symptoms in the DSM. They are mostly adhering to program guidelines as well as through referrals for other problems and they plan on ongoing treatment, so those patients can move to monthly visits. Transfers are required when patients psychiatric or medical concerns become unmanaged or you detect a previously unknown medical or psychiatric concern that is not managed well. Then you need to appropriately explain why, so that patients don't feel punished. It's just how your disease is progressing. Perhaps it had something to do with not adhering to the referrals or to the groups, but that too is how their disease is progressing. So don't make them feel like they're being punished for it. Give them clinically indicated referrals and have a wrap-up visit with them and make sure that there's a linkage to the next treatment. Here is your SMM "cheat sheet". Because it's a "cheat sheet" for you to print out and have, I'm not going to go over all of this, but it has your general stance. It has your initial session elements and starting quotes, very helpful to our providers, follow-up sessions. Again, its elements and starting quotes and how to address frequently asked questions. Again, I encourage you to try it as I described before, there is nothing like role-play. I know it is awkward at times, but this will solidify your ability to do it well. So I want you to find, in closing, remember to discuss this with your colleagues, to apply it as frequently as you can, and to reflect on it and reflect on why you might become eligible to provide SMM in your practice. You might make all the difference in a patient's remission. Here are some references that you can look at your leisure. I also want to make you aware of our PCSS Mentor Program. The mentor programs is designed to offer you general information, especially for clinicians about evidence-based practices including SMM and prescribing the medication. So you can make use of that. It's a national network of providers with expertise in addictions, pain, evidence-based treatment, including medication-assisted treatment. It has a three-tiered approach and allows every mentor/mentee relationship to be unique as needed for you and catered to your specific needs as the mentee, and there is no cost. So if you want more information, go to pcssNOW.org/mentoring. We also have a PCSS discussion forum. If you have a clinical question, ask a colleague. So this is a quicker, less involved way to just post a question. So you can click here and come to that and you can get an answer to your medication-assisted treatment question. They are prompt and to the point. Finally, want to let you know that PCSS training is a consortium and collaboration among many members that you see listed here. Not least of which are the American Academy of Addiction Psychiatry in partnership with the Addiction Technology Transfer Center and many, many others. So please take a look at this. For more information, you can go to the website www.pcssNOW.org or see them at their Twitter handle or Facebook page. Thank you very much for your time and attention. I know this was a lot, but this really lays out a nice structure for you. I wish you and your patients all the best. Thank you very much.
